Transcript Task C - Global Health Care, LLC

E-Learning Management Systems:
Motivate Healthy Habits &
Self-care of Chronic Diseases
Rick Botelho, BMedSci., B.M., B.S., MRCGP (UK)
Professor of Family Medicine and Nursing
Independent Consultant, MHH LLC.,
May 12th, 2003
copyrighted 2003 All rights reserved
RJBotelho MHH LLC
Change Yourself First
I have only three enemies. My favorite
enemy, the one most easily influenced
for the better, is the British Empire. My
second enemy, the Indian people, is far
more difficult. But my most formidable
opponent is a man named Mohandas K.
Gandhi. With him, I seem to have very
little influence.
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RJBotelho MHH LLC
Unhealthy Behavior Epidemics
& Chronic Disease Burden
We are dying from poor health habits:
physical inactivity, junk food consumption,
obesity, tobacco use, passive smoking,
alcohol excess, drug abuse, unsafe sex, not
taking prescribed medications—the list
goes on. We also live a disease-producing
world—the burden of chronic diseases is
escalating. Together, these problems will
far outstrip the capacity of the health care
system to mount an adequate response.
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Mutual Aid & Self-help Approaches
MASH are essential grassroots
approaches (online/offline) for
enhancing the intersectoral response
to these epidemics and burdens.
Such approaches must become the
foundation for developing a MHH
movement.
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The
KISS
Principle
is…….
Unsophisticated
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Behavioral Interventions
Giving information and advice to
others about changing their
unhealthy behaviors is equivalent
to the placebo impact of
nineteenth-century drugs. The use
of this “drug” over and over again,
when it is clearly not working,
could be regarded as a form of
medical error—a patient safety
issue.
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A Multi-theoretical Framework to Behavior Change
Linear and Nonlinear Perspectives
Healthcare politics and policy
(Supports and barriers)
Healthcare system
(Supports and barriers)
Philosophy
Process
Variables
Theories
Individual
work
Behavioral
Outcomes
Goals &
Plans
Value
Compass
Family/ religious/community influences
(Supports and barriers)
Cultural/social/media influences
(Supports and barriers)
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Vision for the Future
Motivational interventions for health
behavior change must become as
sophisticated and individualized as
the 21st century advances in the
genetic treatment of diseases.
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The Glass Ceiling
Sophisticated DMPs are reaching
a glass ceiling effect
on their ROIs
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Old-New Paradigm Transition
 Controlled studies
 CQI and CAS
 Positivistic Science
 Complexity/Chaos theory
 Linear processes
 Nonlinear processes
 Rational
 Emotional
 RCTs
 Social marketing
 ROI
 VOI
 Mechanical metaphors
 Organic metaphors
 Health advisors
 Motivational Guides
 Teaching moments
 Learning Opportunities
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What is the Rate-limiting Step?
The quality and individualization of
the complex process interventions
(online, self-help, mutual help, small
groups, lay and professional
coaching) for changing practitioner
and patient behavior will determine
the ultimate success of any disease
management program.
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What improvements could you
make in your health behaviors?
Now pick a behavior that you know
that you should change, but you really
don’t feel like it?
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Does knowledge change your
health behaviors?
Does your heart rule your head? Are you
trading in short-term, emotional benefits
(heart) against your long-term, physical
health (body)? Do you minimize these
health risks (mind)? Do you value your
health (soul), but you can’t put your good
intentions into action?
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Move Beyond Superficial Change
 Gaining knowledge
 Declaring intentions
 Setting goals
to Deep Change
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To The Heart of Deep Change
 Doing emotional work
 Reflecting about motives
 Changing perceptions and values
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Creating
Learning
Opportunities
Learning environment
 Safety and trust
 Autonomy-supportive
 Secure to explore
 Structured process
 Flexible application
Learning Experiences
 Profound reflection
 Emotionally evocative
 Meaningful events
 TP experiences
 Intrinsic motivation
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Interactive Online Programs:
The Foundation for Blended Learning Methods
Online MASH programs allows
participants to interact with a learning
process in self-directed ways and/or in
small groups. Online groups can develop
supportive, learning communities. These
communities can inform and energize the
learning process, creating emotionally
engaging, growth experiences.
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Blended Learning Methods
Online learning provides a cost-effective,
scalable way of:
-Empowering patients to improve their
health habits and self-care of chronic
diseases
- Learning how to become health coaches to
family and friends
- Helping practitioners change from a
health advisor to a motivational guide and
develop motivational skills
- Developing a MHH movement
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Change Yourself Before
Helping Others
1. Get ready
2. Take charge
3. Make plans
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1. Get Ready for Change
a.
b.
c.
d.
e.
f.
Use a decision balance
Assess resistance and motivation
Assess competing priorities
Assess energy
Assess motives
Assess confidence and ability
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1. Clarifying Issues About Change:
Using a Decision Balance
RTS
RTC
1. Benefits of staying 2. Concerns about
the same
staying the same
3. Concerns about
change
4. Benefits of
change
Resistance
Motivation
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Assess Your Resistance and Motivation
Using the 0-10 scale, 0 means that it is
not important, and 10 means it is very
important……
What number would you give for your
reasons to stay the same?
What number would you give for your
reasons to change?
Assess Your Resistance
Is your score for staying the same based on how
you (choose one):
A) Think
B) Feel
C) Think and feel
What score would you give for your reasons to
stay the same based on you think?
What score would you give for your reasons to
stay the same based on you feel?
Assess Your Motivation
Is your score for changing based on how
you (choose one):
A) Think
B) Feel
C) Think and feel
What score would you give for your
reasons to change based on you think?
What score would you give for your
reasons to change based on you feel?
Task A: Online responses
(E1) I must admit initially I was a little
skeptical about the MASH training but it
fits into place with the solution-focused
and motivational interviewing stuff that I
have been doing over the last four years.
I have very much liked the decision
balance for assessing a person's
motivation to change.
Task A: Online responses
(E1) It is useful when I apply it to my
own issues. It made me think about the
damages that grotty food, too much
alcohol and not enough rest has had on
my body for the last twenty years!! It has
made me value the changes that I had
already made and I realised that I could
take more control of these issues. That
was very rewarding.
Task A: Online responses
(N1) I think the exercise forces you to
evaluate if the change you say you want
to make is really that important to you.
I found that it made me realize that I
wanted to make my change for myself
and not for anyone else!
(N2) This task really made me realize that
even though I want to make a change, I
really haven't found a reason to do it.
(N3) Now I really do want to make a
change, just seeing how external
things keep us in the rut we live in and
that we might need to eliminate
something or someone from our
everyday space in order to do what we
need to do for ourselves.
2. Take Charge of Change
 Lower Resistance
a. Explore why you do not want to change
b. Assess priorities
c. Think about behavior & health over time
d. Take responsibility and makes choices
e. Substitute benefits
f. Change your views about staying the same
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Task B: Lower Resistance
(E1) Hi everyone, Just a couple of points.
Firstly, I am pleased to say that I feel I am
beginning to lower my resistance to
change by facing up to the barriers I put
in the way. It has become apparent that I
had adopted an 'all or nothing' attitude to
my unhealthy behaviour, so I am now
considering how I might look at my habit
in a more rational / realistic way.
Task B: Lower Resistance
The task which asked us to look at our
health / habits five years ago and compare
them to how they are now was a real eye
opener. What was probably the most
useful though, in reducing my resistance,
was forcing myself to explore what my
health might be like in the future if i
continue as I am. This has really stirred up
some strong emotions inside and I think I
will need to process this further before I
share.
Task B: Lower Resistance
(N1)Take this for instance. I fell into the
habit of smoking about 4 cigarettes per
day. Not a big deal, but my mother always
let me know how disappointed she was at
me for doing that to my body. She
remembers how particular I used to be
about fitness. So I made a deal with her. I
told her that if I completely give up
smoking, that she would have to start
weight watchers. She agreed to do this.
Task B: Lower Resistance
So far I haven't had a cigarette in 3 weeks. I
don't even think about it. As far as my mother
goes, she has fell off the weight watchers wagon
several times , but I keep reminding her of my
deal I made with her. So, what I'm trying to say
is that me deciding to change has brought about
other people (my mother) making changes. It is
like a self contained support system, that
regenerates its strength as more changes are
made. Another quote: "...shared success is twice
as nice; shared setbacks hurt only half as much."
2. Take Charge of Change
 Increase Motivation
a. Consider future events happening now
b. Change your values
c. Change your views about changing
d. Challenge your excuses
e. Transfer motivation
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.
Task C: Enhance Motivation
I just completed task C but it waaaaas hard to
do it. It has taken me 3-4 days to get through it.
Much food for thought and a lot of reflection
taking place....My scores don’t really reflect my
internal changes, as I initially underscored my
resistance and overrated my
motivation...Exercise two was a good one as it
made me realize that being healthy and
spiritually balanced was the top priority for me.
My work came 5th so that is an improvement.
Task C: Enhance Motivation
(A) Well this course has helped me to realize
only I can make the change, no one else can start
me or stop me. Just like getting motivated to do
things that help you feel better about yourself,
you just have to pull up your bootstraps and GO
FOR IT
(B) When I think about the future and that I
could get diabetes type II if I don't exercise
regularly and that I might have to be on
medication for the rest of my life it makes me
realize that my little excuses are rather flimsy
and self-indulgent.
Task C: Enhance Motivation
(C) My resistance to change seems to increase
with doing this project. My motivation is
decreasing. I *feel* my motivation to change
impacts others more than it impacts
myself. Although I do believe *do unto others as
you would have them do unto you*, I also have a
part of me that does not want to be driven by
what others think (as I typically live my life
anyway). The behavior change is becoming less
important to me and the things I think I need to
change are becoming more important.
Task C: Enhance Motivation
(G) Maybe you picked something that is not a
priority for you right now and it sounds as
though you are finding other things are more of
a priority to change. That is fine- if you want to
work on another aspect of your life for the rest
of the semester, feel free to change your focus
area. You don't have to be successful with the
project- only apply the steps. I think you have
gained some insight about implementing change
in your life.
3. Make Plans for Change
a. Overcome negative self-talk
b. Use your strengths
c. Take a time-out
d. Suppose a miracle happened
e. Find exceptions
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3. Make Plans for Change
f. Build your confidence
g. Increase your ability
h. Understand addictions
i. Selects goals
j. Prevent lapses and relapses
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Task D: Make Plans
I have finished Task D at long last. I have
had an emotional rollercoaster of a ride,
First I was really excited and could not
wait to get started, then I downloaded the
work and realized there was so much to
read and do in such a short space of time.
It has been a great opportunity to look at
my long standing unhealthy habit.
Task D: Make Plans
My views on this exercise has changed from
being slightly negative (was this because this is
how I viewed myself and my unhealthy habit )
the more I have worked on this, the more self
analysis, soul searching and reflecting I have
done. The more understanding I have about
myself and my unhealthy habit I now view this
exercise in a positive way and felt more positive
about my participation. It has been a good
learning experience. I feel much more prepared
and open and feel ready for the changes I wish to
embark upon.
Task D: Make Plans
(A) Change definitely forces us out of our
comfort zone. Change is always uncomfortable
whether for the good or bad. This session helped
me to see what caused my relapses before when
trying to implement change. Hopefully my plan
for change will work this time! :)
(B) I have found (so far) that in order to get out
of my comfort zone that it took taking that first
step. That is usually the hardest. I found that
before I started my change that I made a million
excuses to not start or take that first step. Once
you get into a routine including your new change
it isn't as hard.
Task D: Make Plans
(A) I don't have problems with negative self-talk
or any of the other negative behaviors, I just feel
so strapped for time, and this definitely requires
time. I know that I have to figure out a way to
make time, but that is easier said than done
(B) Until I was forced to look at how I really feel,
I just went along every day with what was
comfortable, even if it was unhealthy, so I can
agree with you and look forward to seeing more
than just writing down these answers for class
credit, you know what I mean. We are worth it
Non-Responder
I want you to know how valuable this course was
- still is- for me and why I chose not to interact
with the group. I do not know why others did
not post to this board, but I did not post because
this was a very moving and personal experience
for me and I did not feel like sharing in the
discussion boards because I did not feel a level
of relationship close enough with the people in
the group to honestly share at that level. I also
did not want to be phony and superficial instead
- so I did not share at all. I am outside of the
average student in the class.
Non-Responder
Back to the positive - WOW - what an
experience! Yes - I think that this class
should be offered to every class. Just
processing the change in such a personal
and significant way for ourselves helps us as
future practitioners understand what each
and every one of our clients will need to
engage in to make permanent lifestyle
changes to improve their health and lives. I
did each of the exercises before I entered
any data online. BUT - from the first
decision balance - what an eye opener!
Non-Responder
I did the decision balance and then spent a few
days considering why I never thought about it
from that perspective before. The program just
got better helping me understand myself and
now - I have begun a well thought out plan for
change that I view as a permanent lifestyle
change (and I seem happy about that, hmmmm that never happened before!) I have lost 4
pounds already, I do not feel sorry for myself as
in previous diets and attempts at weight loss
and am very happy and satisfied with my
lifestyle CHOICE! I will be doing the follow-up
tasks so look for me there and see how I am
doing.
Non-Responder
I think that immersing us in this project for the
entire semester without the patient component
would be very beneficial. I would have liked
more time to explore these new (to me) ideas and
concepts about motivation. I think it is very easy
to make the connection and transfer what we
have learned about ourselves to our clients. I
liked the on-line format because I think this is a
personal solo adventure, but I know that
"reading and doing" fits my learning style so I
do not know if this is true for all. Thanks again
for a wonderful and MOTIVATING experience.
Overall Impact of the Online MHH Course
on Mean Motivational Scores
A:
D:
Clarifying Implement
Issues
a Plan
Cognitive
Resistance
Emotional
Resistance
Cognitive
Motivation
Emotional
Motivation
Emotional
Work on
Change
Mean
Change
P*
From A to D
3.7
2.8
-0.9
0.004**
4.2
3.3
-0.9
0.003**
7.0
7.4
0.4
0.22
6.5
7.4
0.9
0.002**
4.6
5.9
1.4
0.0001*
* Probability that overall change does not equal 0, from a two-tailed t-test for unpaired data
** Significance to <0.05
Overall Impact of the Online MHH Course
on Mean Motivational Scores
A:
D:
Clarifying Implement
Issues
a Plan
Priority
Energy
Confidence
to change
Ability to
change
Mean
Change
P*
From A to D
6.0
7.2
1.2
0.0001*
5.0
6.5
1.6
0.0001*
6.0
7.6
0.6
0.0001*
6.9
7.9
1.1
.0001*
* Probability that overall change does not equal 0, from a two-tailed t-test for unpaired data
* Significance to <0.05
Overall Impact of the Online MHH Course
on Mean Motivational Scores
A:
D:
Clarifying Implement
Issues
a Plan
Indifference
EC motives
IC motives
FC motives
3.3
4.3
6.4
6.0
2.9
4.2
6.9
6.9
Mean
Change
P*
From A to D
-0.5
0.2
0.6
0.9
0.14
0.64
0.08
0.007*
* Probability that overall change does not equal 0, from a two-tailed t-test for unpaired data
* Significance to <0.05
Readiness to Think about Change
Before
1. Not thinking about change
2. Open to possibility of change
3. Thinking in a superficial way
4. Thinking in an organized way
Mean score
4
15
70
26
2.0
After
0
5
18
86
2.7**
**p<0.0001
Readiness to Take Action
1. Not preparing to change
2. Preparing to change < 6 mths
3. Preparing to change < 3 mths
4. Preparing to change < 1 mth
5. Preparing to change < 1 week
6. Implementing action steps
7. Implementing full action plan
Mean score
Before After
10
2
13
7
8
5
25
11
14
10
41
40
4
34
3.4
4.5
p= <.001**
Summary
The epidemics of unhealthy behaviors and chronic
disease burden far exceed the capacity of all health
care systems worldwide. MASH approaches are
the foundation for health promotion and disease
prevention. These grassroots, bottom-up
approaches (online and offline) must work
synergistically with intersectoral, top-down
approaches. An integrated and transformed (sideto-side) strategy can compete more effectively
against the global, disease-producing influences
(e.g tobacco corporations).
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RJBotelho MHH LLC